Esophageal Cancer Treatment

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Patients with esophageal cancer are benefiting from faster recovery with robot-assisted surgery at UC San Diego Health System

Nearly 20,000 people in the United States are diagnosed with esophageal cancer every year. This cancer is three times more common in men than in women, and most people are diagnosed in their 60s. The two most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma. UC San Diego Health System treats all cancers of the esophagus, and primarily sees patients with adenocarcinoma, which is the most common type in the United States.

Diagnosing Esophageal Cancer

Symptoms of esophageal cancer can include indigestion or heartburn, trouble swallowing, choking, coughing, hoarseness and pain in the throat or breastbone. To diagnose and stage (determine how advanced the cancer is), physicians use endoscopy (a miniature camera placed in the mouth and down the throat) and specialized x-ray techniques.

Picturing Cancer: Diagnostic images show cancer where the esophagus attaches to the stomach. Read more about diagnosis at advanced endoscopy.

An esophagogastroduodenoscopy (EGD), also called an upper endoscopy.

X-ray imaging from a barium swallow test showing esophageal cancer.

Treatment for Esophageal Cancer

Outcomes of Robotic-Assisted Transhiatal Esophagectomy (RATE)

UC San Diego sees significant advantages for patients through use of surgical RATE approach for those who have undergone preoperative chemoradiation. Read more.

Surgery is the most common treatment for esophageal cancer. Radiation therapy or chemotherapy is often done before surgery to shrink the tumor. This is called neoadjuvant therapy.

Since 2006, UC San Diego Health System has treated patients diagnosed with esophageal cancer with a minimally invasive esophagectomy procedure called RATE (robot assisted transhiatal esophagectomy). The results:

minimal blood loss

minimal complications

shorter length of operation

shorter hospital stay

faster recovery

equivalent or better cancer outcomes to open esophagectomy

Development of Surgical Treatment of Esophageal Cancer

Open Esophagectomy

An open esophagectomy refers to the removal of the esophagus through large “open” incisions in the thorax (chest), neck and/or abdomen. The procedure is complicated, takes many hours to perform and results in longer hospital stays and recovery times. Only in rare cases do we perform open esophagectomies at UC San Diego Health System.

Laparoscopic Esophagectomy

In the mid-1990s, minimally invasive techniques for esophagectomy were developed. Early minimally invasive techniques were laparoscopic. Laparoscopy is a form of minimally invasive surgery in which small incisions are made in the abdominal wall through which long, thin surgical instruments are inserted. Miniature video cameras enable surgeons to see and remove the esophagus and affected lymph nodes. For nearly two decades, studies published by academic medical centers around the world reported reduced post operative complications and comparable cancer and survival outcomes when performing laparoscopic esophagectomy instead of open surgery. Many surgeons use this minimally invasive technique today. (Reference: Kim, et al.) At UC San Diego, we combine laparoscopy with robotic technology. Read more about this below.

Anatomy: Approaching the esophagus from the chest or the abdomen

Whether using laparoscopic techniques or an open surgery method, surgeons take different approaches to remove the esophagus. Keep in mind, the esophagus is about 10 inches long and connects the throat to the stomach. To access the esophagus, in order to remove it, the surgeon approaches it in one of two ways. One approach is thoracic, meaning, from the side of the chest. Through this approach, a lung is collapsed to enable access to the esophagus. The other approach is called transhiatal, which requires an abdominal incision.

Esophagectomy Today: Robot-Assisted Transhiatal Esophagectomy

At UC San Diego Health System, our cancer experts treat localized and advanced esophageal cancer using minimally invasive surgical techniques including robotic technology to achieve faster recovery for our patients, and fewer complications than open methods. The “robot” is a minimally invasive tool that has some advantages over traditional laparoscopic tools:

The robotic surgical system provides better visibility inside the body for the surgeon than in laparoscopic techniques because of 3D, high-definition imaging. This is crucial in accessing the esophagus which resides immediately next to other organs.

The robotic surgical system has seven degrees of motion, just like a human wrist; laparoscopic instruments are mostly restricted to four degrees of motion. This means the surgeon has more flexibility and motion control with the robotic surgical instruments than when using traditional laparoscopic surgical instruments. The system also eliminates any minute tremors in the surgeons' hands.

Minimally invasive surgery and robot-assisted surgery is challenging and demands extensive training. Having first reported on this procedure and its outcomes over a decade ago, UC San Diego Health System is one of the most experienced centers in the country in performing robotic surgery. (Reference: Horgan, et al.) Our team of internationally renowned esophageal surgeons is led by chief of minimally invasive surgery Santiago Horgan, MD, and chief of endocrine surgery Michael Bouvet, MD.

What is involved in the procedure to treat patients with esophageal cancer at UC San Diego Health System?

Using robotic surgical techniques and an abdominal (transhiatal) approach, the surgeons detach the esophagus from where it joins the stomach. Then a new esophagus is created by forming a tube out of a portion of the stomach. Any lymph nodes near the esophagus that may be cancerous are removed.

The delicate separation of the esophagus at the throat is performed, carefully preserving endocrine and vocal function. The newly formed esophagus is pulled up (from the stomach) and attached at the throat.

The operation takes approximately four hours and the length of stay in the hospital is typically one week. Our experience with this procedure is that recovery is much easier for patients compared to open esophagectomy.